Question:
How can I have a desperate medical necessity and be denied on benefit exclusion?

I have been told by my kidney specialist, I must have this surgery immediately. He said, I can can have this or be on dialysis within a couple months. I tried to get the surgery approved approximately a year ago, and was denied based on a benefit exclusion. It is hard for me to comprehend they will pay for dialysis, but not WLS. I need help and don't know where to turn. Any ideas will be greatly appreciated. I have contacted Walter, but I am unsure if I can handle the fee if the surgery would still be denied. I will have to have the funds, to pay for dialysis. Please Help, I am desperate.    — Rebecca N. (posted on March 1, 2001)

March 1, 2001
Rebecca, I don't know if your insurance is through your employer or not but if it is your company can go outside of their contract to help you. You might want to approach your employer with ADA issues also. Oh, and depending on your income situation, I understand that Vocational Rehab will also pay for this type of surgery based on the fact that you do have a disability prohibiting you from either, current employment or future employment. Good luck and I will keep you in my prayers.
   — Sharon R.

March 1, 2001
Your basic first question was "How can I have a desperate medical necessity and be denied on benefit exclusion?" To answer that, think about a woman who is 9 months pregnant but whose insurance policy excludes pregnancy benefits. That's how! If you look at ANY insurance policy, whether it be a medical insurance or car insurance or home owners, etc, you will find exclusions. These things simply are not covered under that particular policy. In these cases, aside from asking the company to reconsider your particular circumstances, I think it is futile to fight it. However, I do understand your plight and wish you the best.
   — Cindy H.